massachusetts intern affidavit
FORM B
Professional Credential Services, Inc.
PO Box 198788 ~ Nashville, TN 37219-8689
Preceptor’s Affidavit of Internship Hours
This form is to be submitted each time an intern completes training at a new location.
This form must be filed for each intern supervised by the preceptor.
A
Name of Intern:___________________________________ *Intern Reg. #_______________________
First
Last
(Must be included)
Intern’s E-mail address:_________________________________________________________________
______________________________________________________________________________________
Preceptor’s Name
State License No.
License Expiration Date
_______________________________________________________________________________________________
Name of Pharmacy in which you practice on a full-time basis
_______________________________________________________________________________________________
Pharmacy Location: Street Address
________________________________________________________________________(____)__________________
City
State
Are you the owner of the pharmacy?
B.
Reported Intern
Hours. Provide total hours of internship training under the preceptor’s direct supervision for the specified work period.
Do not duplicate hours accrued.
Zip
Telephone Number
YES NO
NOTICE: Intern’s working period should be reported in 3-6 month increments if the internship is at least 12 months in length.
Intern Dates of Employment:_____________________________________________
From: MM/DD/YY
To: MM/DD/YY
Preceptor’s Initials
Number of Intern Hours completed during the work period stated above:_______________________________________________
(Example: two hundred and forty)
In regards to the intern’s quality of work, has the intern met your expectation level for completeness and neatness of work accomplished? YES NO
C.
Evaluation of
Intern. Answer
each question listed. This form
MUST be mailed to PCS
Professional Credential Services, Inc.
PO Box 198788 ~ Nashville, TN 37219-8689
Preceptor’s Affidavit of Internship Hours
This form is to be submitted each time an intern completes training at a new location.
This form must be filed for each intern supervised by the preceptor.
A
Name of Intern:___________________________________ *Intern Reg. #_______________________
First
Last
(Must be included)
Intern’s E-mail address:_________________________________________________________________
______________________________________________________________________________________
Preceptor’s Name
State License No.
License Expiration Date
_______________________________________________________________________________________________
Name of Pharmacy in which you practice on a full-time basis
_______________________________________________________________________________________________
Pharmacy Location: Street Address
________________________________________________________________________(____)__________________
City
State
Are you the owner of the pharmacy?
B.
Reported Intern
Hours. Provide total hours of internship training under the preceptor’s direct supervision for the specified work period.
Do not duplicate hours accrued.
Zip
Telephone Number
YES NO
NOTICE: Intern’s working period should be reported in 3-6 month increments if the internship is at least 12 months in length.
Intern Dates of Employment:_____________________________________________
From: MM/DD/YY
To: MM/DD/YY
Preceptor’s Initials
Number of Intern Hours completed during the work period stated above:_______________________________________________
(Example: two hundred and forty)
In regards to the intern’s quality of work, has the intern met your expectation level for completeness and neatness of work accomplished? YES NO
C.
Evaluation of
Intern. Answer
each question listed. This form
MUST be mailed to PCS